Are virtual consultations both practical and safe?

The NHS’s new plan promises that ‘over the next five years, every patient will have the right to online digital GP consultations, and that redesigned hospital support will mean up to a third of outpatient appointments will be unnecessary, saving patients 30 million trips to hospital, and saving the health service over £1 billion a year in new expenditure.’

The amount of people using digital services for medical appointments is at its highest yet. Recent figures from NHS Digital show that almost a quarter of patients (14.3 million people) used GP online services to make appointments, view test results and order repeat prescriptions. 

But clinicians – both GPs and hospital doctors – are currently untrained in the art of virtual consultations and many doctors have misgivings about making important clinical decisions about patients without the possibility of performing a physical examination. What are the medico-legal implications if an incorrect diagnosis is arrived at following an e-consultation and the patient suffers harm as a result? Online ‘digital’ consultations certainly have the potential to save money but how well will they work in practice and what retraining will be required?

What are your thoughts and experiences? Have digital consultations already made their presence felt in your practice? Let us have your views by adding a comment to this blog.

Comments (6) Add yours ↓
  1. Nitin Shrotri Consultant Urologist

    It’s definitely worth a try. It is likely to mean slightly more work for the doctor as communication is less than ideal with the accompanying inability to carry out a physical examination. As long as confidentiality can be maintained, for the patient, it could mean a massive advantage in terms of saving their own and relatives travel time, parking charges, contrasted by the lack of an ever decreasing social interaction for the housebound. Payments for the hospital should not be slashed because of use of this mode of clinic attendance. All in all, a good thing, which has been a long time coming.

    January 11, 2019 Reply
  2. Mike Flannigan Retired Urologist

    Dear Roger

    Virtual medicine is essential for the future of any health service. We should embrace it and develop it to maximise the quality of care for everyone and to reduce the crippling costs of modern healthcare.

    It must include video, face to face consultation. We cannot ignore the value of body language in assisting our diagnosis. The patients also have more faith in the consultation when seeing the person offering the advice and help.

    It is only possible because of the introduction of appraisal and revalidation which both ensure the individual healthcare worker is not over-burdened with work, either through his own desire or that of managers, and, anyone offering services is adequately trained for the work.

    Virtual healthcare can be offered at a number of levels:

    1. Outpatients
    2. Emergency Consultations
    3. Interdepartmental Consultations
    4. National and International Consultations

    Healthcare workers can make themselves available;

    1. For regular sessions each week
    2. Randomly during ‘down time’ when not in the main institution
    3. While involved in other activities ie at appropriate times during operating lists, standard outpatient clinics or ward rounds.
    4. In the new world of older retirement ages then ‘on site’ hours can be reduced and ‘at home’ hours used to continue to offer a service.
    5. Where early retirement through illness occurs. The individual can continue to offer a service as long as appraisal identifies no impairment of quality and revalidation confirms adequacy of knowledge.

    Medical indemnity has to be considered and the various Defence Unions will need to address this carefully. Crown indemnity for NHS consultations may also restrict practice or impose specific constraints.

    Medico-legal concerns can be avoided by the use of recording of all consultations. When I investigated the introduction of virtual medicine 10-15 years ago one the first steps we took was to find a digital storage device, with NHS level encryption, which could store 20years of video data.

    This has additional advantages as the medical personnel and patients can be given access to the discussions for reference but also for teaching. With appropriate feedback from students and trainees gold standard teaching sessions for all conditions would quickly become obvious.

    There is no doubt the introduction of such systems leave us all open to more severe scrutiny. The converse obtains, however, where we only offer services in which we are absolute experts.

    I was initially encourage examine virtual medicine when Tony Blair announced in 2002 that by 2004 all homes in the country would have access to fast broadband through their television sets. Sadly we are not there yet.

    My efforts floundered 10-15 years ago because of a lack of demand and concerns over such a critical change in practice. However, one of my colleagues, Tariq Shah, has set up such a system to bring access to high quality healthcare to remote parts of Pakistan. He can sit at home in Bradford, discuss symptoms with patients in Pakistan and advise less experienced healthcare workers, on the ground, how to triage the problems and develop appropriate and rapid diagnosis without the patients having to travel long distances.

    I am taking care not to enumerate the opportunities to save money as this will cause many readers to be concerned that they will lose the ‘family silver’. But when I tried to cost this out 12 years ago I anticipated savings of 25 billion pounds per year, for the NHS, and a significant increase in staffing levels by allowing retired and physically unfit healthcare workers to continue to contribute.

    In short, virtual medicine allows more rapid, more appropriate, more cost effective healthcare across the globe.

    January 11, 2019 Reply
  3. Michael Kirby Professor

    Alternatives to face-to-face GP consultations unlikely to deliver hoped-for benefits in practice NIHR 2018:
    The researchers studied, in depth, how a variety of technological alternatives to GP consultations were being used in eight general practices of different sizes, in different geographical areas – some urban, some rural – and in different areas of socioeconomic deprivation in the UK.

    They found that although there were some potential benefits, there were also significant barriers to implementation, with practices often responding to incentives to introduce new technologies without a clear rationale or clearly thinking through the likely costs and benefits for patients and practice staff

    “Their findings suggest that policy-driven top-down approaches that use financial incentives as a way of encouraging adoption of alternative consultation methods is not the best way forward if efficiencies are to be made. Instead, individual practices should take a considered and tailored approach, based on the needs of their practice population, and available resource, so that there is equitable delivery of care.”

    “The study shows that, currently, GP practices are struggling to identify and implement the most beneficial uses of these new technologies and they are frequently being adopted without sufficient understanding or support.

    “In particular,they identified a tension between the desire to make access to health care easier and more convenient, while at the same time aiming to reduce GP workload.They found that new ways of accessing health care advice may well increase rather than decrease GP workload.”

    Another example:High-profile health app (Babylon) Health under scrutiny after doctors’ complaints:

    The Financial Times tested Babylon’s symptom checker to understand its response to the two conditions at the centre of the first complaint. When told a 66-year-old obese male smoker was experiencing sudden chest pain and excessive sweating, Babylon suggested 9 out of 10 people with similar symptoms were likely to be having a panic attack and made no mention of the risk of a heart attack.

    The Care Quality Commission has stated that:43% of digital health providers, were not providing safe care.
    You cannot beat face to face consultations!!

    January 16, 2019 Reply
  4. Christian Brown Urologist

    I was involved in a pilot of on line consultations for men with foreskin issues 8 years ago. This was part of a wider project with dermatology and plastics. It failed miserably. Primarily due to poor internet links, the quality of the pictures not good enough and poor uptake by patients. Things have moved on and if the technology is in place it should work and be embraced. I cant see any medico legal implications to this as long as a record of the interaction appears on the electronic file and a picture stored which is common place nowadays e.g. flexible cystoscopy.

    Virtual clinics are an easy win. Great for patients and providers alike. With increasing numbers of diagnostics being required for benign asymptomatic conditions such as non visible haematuria a VC to give patients the good news their scan was normal, or to follow up patients after curative prostate cancer treatments with PSA seems ideal. The challenge for the secondary provider is the documentation of this consultation and remuneration. Tariffs can be agreed and as long as the interaction is recorded the hospital can be paid. Its my experience that VCs are quicker and so leaving more time and increasing access for other patients who need a physical visit.

    January 23, 2019 Reply
  5. Roger Kirby Professor of Urology

    Introducing video consultations in NHS hospitals, despite well-documented advantages to patients, is not likely to be easy, quick or cheap. The five-year target cited in the new NHS Long-Term Plan seems overly ambitious in the light of other countries’ experiences. Norway, for example, initiated a five-year programme to provide digitally-enabled hospital consultations in 2009. Research published in 2015 showed that despite generous funding and a strong policy push (which led to 75 per cent of hospitals signing up to the initiative), the proportion of outpatient consultations conducted by video link was only 2 per cent by 2013.

    February 5, 2019 Reply
  6. Funsho Abogunrin Consultant Urologist

    Whilst virtual consultation will not suit or be for every clinician, patient or medical conditions, there is definitely a role for its use in the NHS.
    I am sure many a clinician have tried and are successfully using telephone consultation for follow up of their patients.
    In the NHS trust I currently work in, telephone consultations has definitely helped make a huge inroad into the backlog of patients perennially waiting out patient review, saving patients unnecessary trips to the clinic. Once adequately informed, patients are delighted with the convenience.
    Whilst face to face consultation is the current “gold” standard, the typical 80yr old, travelling 100 mile round trip, niece taking time of work to facilitate this for “a barely bum in seat, hello, how are things? fine, see you in 6 months” chat will do very well with a virtual consult for example.
    Up scaling to a video call is not far removed from audio calls. Unlike telephones, current heterogeneity of patients equipment for video calls, know how, availability etc will be an issue although with the appropriate will, not an insurmountable one.
    Virtual robotic surgery is already being muted so virtual clinics is definitely not a far stretch.

    February 16, 2019 Reply

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